Transitions of Care RN Case Manager

Your Responsibilities and Impact

Working with patients
Engaging with our newly discharged patients telephonically to understand their needs, supported by technology and data tools.
Conducting assessments to identify comorbid conditions, ED/hospitalization history, medications, psychosocial factors, and patient values and preferences.
Developing care plans in partnership with patients and their caregivers - problems, goals, interventions - while continuously evaluating the patient’s progress.
Explaining complicated medical terms in plain language.
Educating patients on their chronic conditions including teaching “red flags,” developing plans during an exacerbation, and identifying barriers to important care elements such as medication adherence.
Hearing the red flags and providing active care management to close the gaps.
Working With Other Providers And Resources
Partnering with the TOC Nurse Practitioners and Physicians to ensure smooth handoffs, comprehensive follow-up, and coordinated care during the post-discharge period.
Referring patients to Devoted Medical when applicable and working closely on partnering for patient care.
Working closely with Devoted Community Guides (locally-based social workers) to identify community-based organizations to support our patients in meeting their goals.
Coordinating post-treatment care and DME needs.
Collaborating closely with our PCP partners, to coordinate care and deliver evidence based, effective, and accessible health care.

Required skills and experience

• An unrestricted Compact RN license obtained in the United States with the ability to secure other licensure states
• 3-4 Years of Experience of RN Care Management/telephonic case management experience
• Working hours are Monday-Friday 8:30-5:00 MST/PST
• We are looking for candidates who are located in CT/MT/PT time zones

Pay Range

Salary Range: $85,000 - $100,000 / year

Our Total Rewards Package

• Employer sponsored health, dental and vision plan with low or no premium
• Generous paid time off
• $100 monthly mobile or internet stipend
• Stock options for all employees
• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
• Parental leave program
• 401K program